*2.1.2 Contraceptives: when you already know what you want but you cannot and you want to avoid it!*

In the twenty-first century and despite advances in technology and communications, there are still problems with advising patients with SLE regarding contraception [4]. It is a vital part of the strategy to control the decrease in perinatal morbidity and mortality that women with SLE can access information on contraceptive methods and always according to the activity of the disease and the risk factors that each one of them has individually. Despite of that can increase in a prospective observational study of 86 patients, 59% had no advice regarding contraception despite using highly teratogenic drugs, 22% used contraceptives, and 53% only used barrier methods [5].

Looking at the existing literature and evidence, it could be said that we are slowly finding "clarity in a world of greys." On the one hand, it was shown in a case–control study that there is a higher risk of developing disease activity in women aged 18–45 years who are using contraceptives based on combinations of estrogens or progestins with high doses of ethinylestradiol and that the time of starting the intake is recent [6]. On the other side of the coin, we find two randomized controlled trials that showed that the combination of estrogen and progestin or progestin alone does not increase the incidence of thrombotic events in patients as long as they have low or no disease activity and that there is no previous history of thrombosis and negative aPL titers [7]. On the contrary, in patients who are positive with high titers of antiphospholipid antibodies (whether or not they have antiphospholipid syndrome) added to risk factors for developing thrombotic events in which contraception with estrogen-based preparations (oral pill, vaginal ring, and patch transdermal) is contraindicated. In young women with a history of coronary thrombosis (myocardial infarction), cerebral thrombosis (ischemic stroke), and who have a positive lupus anticoagulant, the use of the combined pill increased the risk of thrombotic events at the arterial level [8].

However, in patients who are on strict anticoagulation and who generally have a low-risk antiphospholipid profile, progestogen alone (pill, depot subcutaneous injections) could be considered, provided there was no history or no high risk of thrombosis. Intrauterine devices (IUDs), such as the copper one, can be used in any patient with SLE relatively safely [1, 3]. The levonorgestrel-containing IUD could be used as long as the risks vs. benefits are weighed, and this by reviewing each patient individually. For emergency contraception, the progestogen combination is not contraindicated.
